The Team Approach to Orthotic Management in Quadriplegia

The Team Approach to Orthotic Management in Quadriplegia by Wayne R. Rosen, C O .

Janie J. McColey, O.T.R. John H. Bowker, M.D.

This article presents the approach to orthotic intervention in quadriplegia taken at the Uni­versity of Miami/Jackson Memorial Rehabilita­tion Center. To begin, it must be emphasized that quadriplegia implies not only loss of walking, but also loss of normal use of the hands. Since our hands are the tools with which we sustain life, a major goal of rehabilitation must be to restore the ability to independently carry out common activities of daily living such as feeding, grooming, and manipulation of de­vices which may allow resumption of educa­tional and vocational goals.9 As health care professionals in the rehabilitation field, we must be aware of advances in technique and equipment which can enhance the ever-in­creasing life span of this young population whose educational, economic, and social prog­ress has been so severely curtailed.5 ,6 The role of the orthotist and occupational therapist as members of the rehabilitation team is to address this very underemphasized problem of upper limb management.

When the spinal cord team is first asked to evaluate and treat a newly injured quadriplegic patient, they must take into consideration all aspects of care, not just those in their individual areas of specialization. During the acute med­ical phase, the emphasis is on preserving life and preventing further neurological damage. At this stage, there is little concern for joint posi­tioning or splinting. After life-threatening

problems have been addressed, however, prompt management of the upper limbs is of primary importance if we are to avoid joint stiffness and/or deformity which would inter­fere with the progression of rehabilitation.1 3 , 1 4

This approach to the upper limbs involves a number of basic methods: frequent joint range of motion, limb positioning with and without positioning devices (temporary and perma­nent), dynamic orthoses (temporary and perma­nent), and externally powered orthoses. In our facility, spinal cord injured patients are initially placed on Roto-Rest beds. These beds, with their continuously alternating side-to-side mo­tion, have proven to have a positive effect on the respiratory, renal and circulatory systems, as well as providing skin protection for the S.C.I, patient.3 There is, however, potential for loss of glenohumeral and scapular mobility with its use for extended periods. We have cur­rently adapted the bed so as to allow posi­tioning of the shoulders in abduction and ex­ternal rotation, alternating with the usual ad­duction and internal rotation. This change of shoulder position has been included in our reg­ular routine of joint range of motion and should reduce the pain and stiffness that often inter­feres with arm placement and coordination.1 3 , 1 4

Elbow flexion-forearm supination deformity is another potential problem, especially in C5 quadriplegics.1 This may be managed by posi­tioning the elbow in extension and pronation

between range of motion sessions. The use of thermoplastic elbow-extension splints (Figure 1), bivalved casts (Figure 2), or serial casting (Figure 3), will assist the therapist in main­taining proper position. Functional hand posi­tion should be maintained with the use of a resting hand splint (Figure 4) or a functional long opponens splint with C-bar and lumbrical bar (Figure 5), to avoid the development of a flat "simian" hand.

Once the patient is medically stable, he is able to begin a more active phase of rehabilita­tion, including the use of functional orthoses, if appropriate. His response to this whole process depends largely on the success of the first few days, which in turn depends on how the treat­ment team constructs the patient's first experi­ences of sitting, trunk balancing, and functional arm placement. Only when control of these factors is satisfactory will it be appropriate to introduce orthoses for function. This becomes a critical point in time for the patient and thera­pist, because two possible approaches to future functional activities exist. The first approach is based on the use of adaptive devices which will allow some patients to perform specific func­tions such as self-feeding and oral-facial hy­giene. However, it is our feeling that even at this early stage, multipurpose temporary func­tional orthoses must be introduced if definitive orthoses are to play a useful part in the patient's life. Therapists should be prepared to fabricate and properly fit a training orthosis, which will

Figure 1. Elbow Control Orthosis.

F igure 2 . Bi­valved plaster cast.

allow the patient reasonable options in devel­oping his functional goals. 2 , 9 , 1 0 , 1 2

The following chart provides guidelines for management techniques according to the level of remaining neurologic function. Many of the orthotic options listed in the "Recommended Management" column are from the N.Y.U. Upper Extremity Orthotics Manual.7

The guidelines listed above have been gener­ally accepted throughout the world as the ra­tional basis for orthotic intervention. The fol­lowing variables, however, must receive equal consideration before an orthosis can be suc­cessfully fit to a patient.

Locality The patient should reside not only reasonably

close to a facility capable of adjusting his orthosis, but should have accessible transporta­tion available if a problem arises.

Cost Sufficient funds must be allocated to cover

not only the initial cost of the orthosis pre­scribed but also maintenance and replacement as necessary.15 Figure 3. Serial casting (Plaster of Paris).

Figure 4. Thermoplastic resting splint.

Gadget Tolerance The patient must have the patience to don

and doff the orthosis or he will discard it be­cause it "takes too long to apply." He may then actually prefer to sacrifice his independent performance of intricate manual tasks by either choosing a less effective piece of adaptive equipment or relying on another person for as­sistance. We, as practitioners, must monitor the attitude of a candidate to be sure that the func­tion of the orthosis will be greater than the per­ceived inconvenience of wearing i t . 2 , 1 5

Dominance

The hand preferred prior to injury for writing and activities of daily living will usually be maintained as the dominant hand. This hand should be fit initially and the patient's progress monitored with specific activities before fitting the nondominant hand. Specific activity usage will determine whether or not the second orthosis is indicated.9

Vocation/Avocation

The patient's ability to perform fundamental activities of daily living is basic to maximum restoration, but it is equally important to deter­mine additional intended uses of the orthosis, both vocationally and avocationally (i.e., manual work, desk work, telephone answering services). These data will help determine the type of materials suitable for fabrication or even the type of orthosis that would best suit the individual's needs. 1 2

Psychological/Familial Roles Assessment of the patient's psychological

status is vital in establishing a treatment plan. Psychological make-up of the individual can play a very large role as to whether or not the patient will accept an orthosis. In this regard, cosmesis may play as important a role as func­tion when dealing with a person's already al­tered body image. Psychological intervention is necessary to assist the patient through the stages of denial, anger, and depression to final adaptation. Indeed, the team members may need help in dealing with their own value systems regarding quality of life in relation to long term disability.

The personalities of the patient and family members, as well as those of the orthotist and occupational therapist, play important roles in rehabilitation after a spinal cord injury. An air of confidence emanates from professionals who are comfortable and confident with the task at hand. This confidence can be passed on to the patient, who will in turn become comfortable and confident with the orthosis being fitted. Too often, however, therapists and orthotists are not comfortable with the intricacies of fa­bricating upper limb orthoses, leaving the pa­tient at a disadvantage as he begins his rehabili­tation process, in that he may not be made aware of all the options available, but rather only those preferred by the professionals. Therefore, it is necessary to assemble a team of practitioners who are well versed in all aspects of their respective specialties so as to not hinder the patient in an already stressful situation. Family support is also extremely important as a

Figure 5. Long opponens with MCP extension stop.

reinforcement of professional recommenda­tions. Clear, concise instructions should be given to the patient and family members in order to increase the effective use of the orthosis. 9 , 1 0

Economics Since most orthotists in private practice

cannot afford the luxury of skill maintenance for the small part of orthotic practice repre­sented by upper limb orthotics, the majority of these devices are being made in an institutional setting, where an orthotist and occupational therapist on staff service the needs of quadri­plegics. More time and energy can then be de­voted, with less concern for monetary return, to fabrication and fitting of a complex device such as a wrist-driven prehension orthosis. Being on-site means quicker response time to the pa­tient with no travel time for the practitioner, which also means that more time can be spent actually working with the patient as the need for adjustment arises. The expertise afforded by a qualified and skilled team of practitioners to the patient can only help an already trying and difficult situation.9

Through a team approach to orthotic evalua­tion of the spinal cord injured patient, the best orthosis for that individual should be provided. That does not necessarily mean the most com­plex or expensive orthosis. It means that, given a specific clinical picture, an orthosis is chosen

based on all the factors previously discussed. The purpose of setting standards and guidelines is to increase the success rate of our patients, in allowing them every opportunity to return to a meaningful lifestyle. When this occurs, we as practitioners have done our job and can con­sider the input of our specialty a success. Con­versely, our failures have a negative effect on both the patient and the practitioner. For the pa­tient, it becomes a setback in that his hospital stay may be extended or, more importantly, the potential for independence may be lost because of rejection of the orthosis. For the practitioner, it may be not only a time of second-guessing, but a learning experience at the patient's ex­pense.

Our approach to fitting of functional orthoses is as follows. All candidates for wrist driven prehension orthoses are initially fitted by the occupational therapist with a temporary training orthosis, namely the Rehabilitation In­stitute of Chicago (R.I.C.) tenodesis splint (Figure 6). The patient then trains for a period of time determined by the therapist. Once he has mastered this device, he can be fit by the orthotist with a definitive orthosis. The choice at our facility is the Engen wrist-driven prehen­sion orthosis (Figures 7, 8, and 9). We feel this device best suits our needs because of ease of fit, adjustability, and cosmesis.8 The occupa­tional therapist trains the patient to use his orthosis for activities of daily living, including

Figure 6. R.I.C., Ten­odesis (temporary) splint with wrist ex­tended and fingers ap­posed.

the important function of self-catheterization of the bladder.4 By virtue of thorough training, we feel the acceptance rate of orthoses is in­creased.

Unfortunately, our success rate with the Ex­ternally Powered Prehension Orthosis (EPPO) has not been as favorable as that of the wrist driven type (Figure 10). Two-thirds of all EPPOs that have been fit at our institution have not been used long-term. The feedback from our patients is that they were trained throughout the long rehabilitation process to adapt with the aid of special equipment and then, just prior to discharge, given a brace to replace the adaptive equipment. The patient who spent four to six months in the rehabilitation facility would have perhaps a week to learn to function with his new orthosis. It is hardly surprising that, in most cases, the orthosis was discarded in favor of the adapted equipment with which they were familiar. The problem has been, that for high cervical injuries, a training version of an exter­nally powered prehension orthosis does not exist. This problem could be solved by devel­opment of a training EPPO in which the com­ponents could be reused on different patients. The only parts of the orthosis that would need to be custom-made would be the hand shells.

The cost to the patient for these would be min­imal and in the long run we could save the pa­tient the cost of a very expensive "closet trophy" if he proved to be a poor candidate. We have initiated this project as a joint effort of the Occupational Therapy Department and the Department of Orthotics.

Summary The fabrication and fitting of functional

upper limb orthoses in quadriplegia requires close team work, especially between the ortho­tist and occupational therapist if the ultimate goal of acceptance of the orthosis as a useful aid to activities of daily living is to be achieved. We feel strongly that quadriplegics with wrist extensors should be fitted early with a functional training orthosis rather than sup­plied with activity-specific adaptive equipment. A confident, caring attitude on the part of the occupational therapist and orthotist can also do much toward achieving this goal. For quadri­plegics with shoulder and elbow motion but no wrist extension, a training version of an exter­nally powered prehension orthosis is badly needed for evaluation prior to ordering a defini­tive device. Success in the fitting of complex

Figure 7. Wrist-driven prehension orthosis with wrist in neutral position and fingers open—Ranchos Los Amigos type.

Figure 8. Wrist-driven prehension orthosis with wrist extended and fingers apposed— Engen type.

F ig u re 9 ( b e l o w ) . Wrist-driven prehen­sion orthosis (Modified N . Y . U . - I . R . M . system).

orthoses such as these requires almost unlim­ited "gadget-tolerance" on the part of the prac­titioner, if not the patient. The ultimate profes­sional responsibility is to be equipped with both the manual skills and the objectivity to intro­duce all available options to our patients for their acceptance or rejection.

Authors Wayne R. Rosen, C O . , C.P.E.D., is Chief Orthotist,

Department of Prosthetics and Orthotics at the University of Miami/Jackson Memorial Rehabilitation Center, 1611 N.W. 12th Avenue, Miami, Florida 33136.

Janie J. McColey, O.T.R., is the Supervisor of Occu­pational Therapy, Spinal Cord Unit at the University of Miami/Jackson Memorial Rehabilitation Center in Miami.

John H. Bowker, M . D . , is Professor and Associate Chairman of the Department of Orthopaedics and Rehabili­tation at the University of Miami School of Medicine and Medical Director of the University of Miami/Jackson Me­morial Rehabilitation Center in Miami, Florida.

Figure 10. Externally powered prehension orthosis.

References 1 Abrahams, D. , R.D. Shrosbree, and A.G. Key, "A

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8 Lamb, Jr., C.R., A.J. Booth, and M.E. Godfrey, "Flexor Hinge Splint: Modification to Allow Radial De­viation," Archives of Physical Medicine and Rehabilita­tion, 55, July, 1974, pp. 3 2 2 - 3 2 3 .

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1 5 Zrubecky, G. and M. Stoger, "The Orthosis for Res­toration of Prehensile Function in Tetraplegics," Para­plegia, 11, 1973, pp. 2 2 8 - 2 3 7 .